Environmental Strategies to Reduce Infections

Transcription

1 Environmental Strategies to Reduce Infections William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety; Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology University of North Carolina at Chapel Hill and UNC Health Care, Chapel Hill, NC Disclosure: Clorox

2 Environmental Strategies to Reduce Infections Environmental Infection Control Reprocessing reusable medical/surgical instruments Hospital surfaces Water Identify at least four ways infection prevention activities can reduce the contribution of the environment to HAIs

3 disinfectionandsterilization.org

4 Environmental Strategies to Reduce Infections Environmental Infection Control Reprocessing reusable medical/surgical instruments Hospital surfaces Water Identify at least four ways infection prevention activities can reduce the contribution of the environment to HAIs

5 DISINFECTION AND STERILIZATION EH Spaulding believed that how an object will be disinfected depended on the object s intended use CRITICAL - objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-level disinfection[hld]) that kills all microorganisms but high numbers of bacterial spores NONCRITICAL - objects that touch only intact skin require lowlevel disinfection

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7 Newer Trends in Sterilization of Patient Equipment Alternatives to ETO-CFC ETO-CO 2, ETO-HCFC, 100% ETO New Low Temperature Sterilization Technology Hydrogen peroxide gas plasma-most common Vaporized hydrogen peroxide-limited clinical use Ozone and hydrogen peroxide-not FDA cleared Nitrogen dioxide-not FDA cleared

8 Rapid Readout BIs for Steam Now Require a 1-3h Readout Compared to 24-48h

9 Super Rapid Readout Biological Indicators Commercially available in early BI (blue cap) Monitors 270 F and 275 F gravity displacement steam sterilization cycles 30 minute result (from 1 hour) 1492V BI (brown cap) Monitors 270 F and 275 F dynamic-air-removal (pre-vacuum) steam sterilization cycles 1 hour result (from 3 hours)

10 DISINFECTION AND STERILIZATION EH Spaulding believed that how an object will be disinfected depended on the object s intended use CRITICAL - objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-level disinfection[hld]) that kills all microorganisms but high numbers of bacterial spores NONCRITICAL - objects that touch only intact skin require lowlevel disinfection

11 High-Level Disinfection of Semicritical Objects Exposure Time > 8m-45m (US), 20 o C Germicide Concentration Glutaraldehyde > 2.0% Ortho-phthalaldehyde 0.55% Hydrogen peroxide* 7.5% Hydrogen peroxide and peracetic acid* 1.0%/0.08% Hydrogen peroxide and peracetic acid* 7.5%/0.23% Hypochlorite (free chlorine)* ppm Accelerated hydrogen peroxide 2.0% Peracetic acid 0.2% Glut and isopropanol 3.4%/26% Glut and phenol/phenate** 1.21%/1.93% *May cause cosmetic and functional damage; **efficacy not verified

12 Semicritical Equipment Reprocessing semicritical items has been shown to have a narrow margin of safety Generally, the narrow margin of safety attributed to high microbial load and complex instruments with lumens Any deviation from the recommended reprocessing protocol can lead to the survival of microorganisms and an increased risk of infection Problems encountered with reprocessing semicritical equipment often related to improper cleaning

13 Reprocessing Semicritical Items New Developments in Reprocessing Endoscopes Laryngoscopes Infrared coagulation device Nasopharyngoscopes Endocavitary probe Prostate biopsy probes Tonometers

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15 Effectiveness of Endoscope Reprocessing Infect Control Hosp Epidemiol 2013;34:309 Practice of reprocessing endoscopes and effectiveness evaluated in 37 services (Brazil) Contamination of at least 1 scope identified in 34 (96%) of 37 services Bacteria, fungi and/or mycobacteria isolated from 84.6% (33/39) of the colonoscopes (110-32,000CFU/ml) and from 80.6% (50/62) of the gastroscopes (100-33,000CFU/ml) Not all services followed guidelines; patients were exposed to diverse pathogens

16 MULTISOCIETY GUIDELINE ON REPROCESSING GI ENDOSCOPES, 2011 Petersen et al. ICHE. 2011;32:527

17 Multi-Society Guideline for Reprocessing Flexible Gastrointestinal Endoscopes, 2011 Since 2003, changes in High-level disinfectants Automated endoscope reprocessors- one AER with cleaning claim Endoscopes Endoscopic accessories However, efficacy of decontamination and high-level disinfection is unchanged and the principles guiding both remain valid Additional outbreaks of infection related to suboptimal infection prevention practices during endoscopy or lapses in endoscope reprocessing (unfamiliarity with endoscope channels, accessories, attachments; gaps in infection prevention at ASC; care of intravenous lines and administration of anesthesia or other medications (reuse of needles and syringes, multidose vials)

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20 Reprocessing of Rigid Laryngoscopes JHI 2008;68:101; ICHE 2007;28:504; AJIC 2007;35:536 Limited guidelines for reprocessing laryngoscope s blades and handles Many hospitals consider blade as semicritical (HLD) and handle as noncritical (LLD) Blades linked to HAIs; handles not directly linked to HAIs but contamination with blood/opim suggest its potential and blade and handle function together Ideally, clean then HLD/sterilize blades and handles (UNCHC-blades wrapped in a tray-sterrad; handle wrapped in tray [without batteries]- steam); the blades and handles placed together in a Ziploc bag. Blades and handles checked for function prior to packaging.

21 Contamination of Laryngoscope Handles J Hosp Infect 2010;74:123 55/64 (86%) of the handles deemed ready for patient use positive for HA pathogens (S. aureus, enterococci, Klebsiella, Acinetobacter) Anesth Analg 2009;109:479 30/40 (75%) samples from handles positive (CONS, Bacillus, Streptococcus, S. aureus, Enterococcus) after cleaning AANA J 1997;65:241 26/65 (40%) of the handles and 13/65 (20%) of the blades were positive for occult blood. These blades and handles were identified as ready for patient use.

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24 Laryngoscopes Blades The Joint Commission, FAQ, October 24, 2011 How should we process and store laryngoscope blades? Processed via sterilization or HLD Packaged in some way Stored in a way that prevents recontamination. Examples of compliant storage include, but are not limited to, a peel pack post steam sterilization (long-term) or wrapping in a sterile towel (short term) Should not place unwrapped blades in an anesthesia drawer

25 DISINFECTION AND STERILIZATION Rutala, Weber, HICPAC EH Spaulding believed that how an object will be disinfected depended on the object s intended use CRITICAL - objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-level disinfection[hld]) that kills all microorganisms but high numbers of bacterial spores NONCRITICAL - objects that touch only intact skin require lowlevel disinfection

26 LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Germicide Exposure time > 1 min Use Concentration Ethyl or isopropyl alcohol 70-90% Chlorine 100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Improved hydrogen peroxide (HP) 0.5%, 1.4% UD=Manufacturer s recommended use dilution

27 IMPROVED HYDROGEN PEROXIDE (HP) SURFACE DISINFECTANT Advantages 30 sec -1 min bactericidal and virucidal claim (fastest non-bleach contact time) 5 min mycobactericidal claim Safe for workers (lowest EPA toxicity category, IV) Benign for the environment; noncorrosive; surface compatible One step cleaner-disinfectant No harsh chemical odor EPA registered (0.5% RTU, 1.4% RTU, wet wipe) Disadvantages More expensive than QUAT

28 BACTERICIDAL ACTIVITY OF DISINFECTANTS (log 10 reduction) WITH A CONTACT TIME OF 1m WITH/WITHOUT FCS. Rutala et al. ICHE. 2012;33:1159 Improved hydrogen peroxide is significantly superior to standard HP at same concentration and superior or similar to the QUAT tested Organism IHP-0.5% 0.5% HP IHP Cleaner-Dis 1.4% 1.4% HP 3.0% HP QUAT MRSA >6.6 <4.0 >6.5 <4.0 < VRE >6.3 <3.6 >6.1 <3.6 < MDR-Ab >6.8 <4.3 >6.7 <4.3 <4.3 >6.8 MRSA, FCS >6.7 NT >6.7 NT <4.2 <4.2 VRE, FCS >6.3 NT >6.3 NT <3.8 <3.8 MDR-Ab, FCS >6.6 NT >6.6 NT <4.1 >6.6

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30 Hospital Privacy Curtains (pre- and post-intervention study; sampled curtain, sprayed grab area 3x from 6-8 with 1.4% IHP and allowed 2 minute contact; sampled curtain)

31 Decontamination of Curtains with Activated HP (1.4%) Rutala, Gergen, Weber CP for: Before Disinfection CFU/5 Rodacs (#Path) After Disinfection CFU/5 Rodacs (#Path) MRSA 330 (10 MRSA) 21*(0 MRSA) 93.6% MRSA 186 (24 VRE) 4* (0 VRE) 97.9% MRSA 108 (10 VRE) 2* (0 VRE) 98.2% VRE 75 (4 VRE) 0 (0 VRE) 100% VRE 68 (2 MRSA) 2* (0 MRSA) 97.1% VRE 98 (40 VRE) 1* (0 VRE) 99.0% MRSA 618 (341 MRSA) 1* (0 MRSA) 99.8% MRSA 55 (1 VRE) 0 (0 MRSA) 100% MRSA, VRE 320 (0 MRSA, 0 VRE) 1* (0 MRSA, 0 VRE) 99.7% MRSA 288 (0 MRSA) 1* (0 MRSA) 99.7% % Reduction Mean 2146/10=215 (432/10=44) 33*/10=3 (0) 98.5% * All isolates after disinfection were Bacillus sp; now treat CP patient curtains at discharge with IHP

32 Environmental Strategies to Reduce Infections Environmental Infection Control Reprocessing reusable medical/surgical instruments Hospital surfaces Water Identify at least four ways infection prevention activities can reduce the contribution of the environment to HAIs

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34 TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In: SHEA Practical Healthcare Epidemiology (Lautenbach E, Woeltje KF, Malani PN, eds), 3 rd ed, 2010.

35 TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In: SHEA Practical Healthcare Epidemiology (Lautenbach E, Woeltje KF, Malani PN, eds), 3 rd ed, 2010.

36 ENVIRONMENTAL CONTAMINATION ENDEMIC AND EPIDEMIC MRSA Dancer SJ et al. Lancet ID 2008;8(2):101-13

37 FREQUENCY OF ACQUISITION OF MRSA ON GLOVED HANDS AFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES No significant difference on contamination rates of gloved hands after contact with skin or environmental surfaces (40% vs 45%; p=0.59) Stiefel U, et al. ICHE 2011;32:

38 ACQUISITION OF MRSA ON HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES

39 TRANSFER OF MRSA FROM PATIENT OR ENVIRONMENT TO IV DEVICE AND TRANSMISSON OF PATHOGEN

40 TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In: SHEA Practical Healthcare Epidemiology (Lautenbach E, Woeltje KF, Malani PN, eds), 3 rd ed, 2010.

41 ACQUISITION OF C. difficile ON PATIENT HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES AND THEN INOCULATION OF MOUTH

42 FACTORS LEADING TO ENVIRONMENTAL TRANSMISSION OF CLOSTRIDIUM DIFFICILE Stable in the environment Low inoculating dose Common source of infectious gastroenteritis Frequent contamination of the environment Susceptible population (limited immunity) Relatively resistant to disinfectants

43 C. difficile Environmental Contamination Rutala, Weber. SHEA. 3 rd Edition Frequency of sites found contaminated~10->50% from 13 studies-stethoscopes, bed frames/rails, call buttons, sinks, hospital charts, toys, floors, windowsills, commodes, toilets, bedsheets, scales, blood pressure cuffs, phones, door handles, electronic thermometers, flow-control devices for IV catheter, feeding tube equipment, bedpan hoppers C. difficile spore load is low-7 studies assessed the spore load and most found <10 colonies on surfaces found to be contaminated. Two studies reported >100; one reported a range of 1->200 and one study sampled several sites with a sponge and found 1,300 colonies C. difficile.

44 Thoroughness of Environmental Cleaning Carling et al. ECCMID, Milan, Italy, May DAILY CLEANING TERMINAL CLEANING % Cleaned Mean = 32% >110,000 Objects HEHSG HOSP IOWA HOSP OTHER HOSP NICU OPERATING ROOMS ICU DAILY EMS VEHICLES AMB CHEMO MD CLINIC LONG TERM DIALYSIS

45 EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI Study design: Retrospective cohort analysis, Setting: Medical ICU at a tertiary care hospital Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge Results (acquisition of CDI) Admission to room previously occupied by CDI = 11.0% Admission to room not previously occupied by CDI = 4.6% (p=0.002) Shaughnessy MK, et al. ICHE 2011;32:

46 ALL TOUCHABLE (HAND CONTACT) SURFACES SHOULD BE WIPED WITH SPORICIDE High touch objects only recently defined (no significant differences in microbial contamination of different surfaces) and high risk objects not epidemiologically defined.

47 C. difficile spores

48 DISINFECTANTS AND ANTISEPSIS C. difficile spores at 10 and 20 min, Rutala et al, 2006 ~4 log 10 reduction (3 C. difficile strains including BI-9) Bleach, 1:10, ~6,000 ppm chlorine (but not 1:50) Chlorine product, ~19,100 ppm chlorine Chlorine product, ~25,000 ppm chlorine 0.35% peracetic acid 2.4% glutaraldehyde OPA, 0.55% OPA 2.65% glutaraldehyde 3.4% glutaraldehyde and 26% alcohol

49 SURFACE DISINFECTION Effectiveness of Different Methods Technique (with cotton) C. difficile Log 10 Reduction (1:10 Bleach) Saturated cloth 3.90 Spray (10s) and wipe 4.48 Spray, wipe, spray (1m), wipe 4.48 Spray 3.44 Spray, wipe, spray (until dry) ppm chlorine pop-up wipe 3.98 Non-sporicidal wipe >2.9 Rutala, Gergen, Weber. ICHE, In press

50 REDUCTION IN CDI INCIDENCE WITH ENHANCED (DAILY AND TERMINAL) ROOM DISINFECTION Before-after study of CDI incidence rates in two hyperendemic wards at a 1,249 bed hospital Intervention: Change from cleaning rooms with QUAT to bleach wipes (0.55% Cl) for both daily and terminal disinfection Results: CDI incidence dropped 85% from 24.2 to 3.6 cases per 10,000 pt-days (p<0.001); prolonged median time between HA CDI from 8 to 80 days Orenstein R, et al ICHE 2011;32:1137

51 Daily Disinfection of High-Touch Surfaces Kundrapu et al. ICHE 2012;33:1039 Daily disinfection of high-touch surfaces (vs standard-cleaned when soiled) with sporicidal disinfectant in rooms of patients with CDI and MRSA reduced acquisition of pathogens on gloved hands after contact with surfaces

52 CONTROL MEASURES C. difficile Disinfection In units with high endemic C. difficile infection rates or in an outbreak setting, use dilute solutions of % sodium hypochlorite (e.g., 1:10 dilution of bleach) for routine disinfection. (Category II). We now use sporicidal solution (chlorine, not floors) in all CDI rooms for routine daily and terminal cleaning (formerly used QUAT in patient rooms with sporadic CDI). One application of an effective product covering all touchable surfaces to allow a sufficient wetness for > 1 minute contact time. Chlorine solution normally takes 1-3 minutes to dry. For semicritical equipment, glutaraldehyde (20m), OPA (12m) and peracetic acid (12m) reliably kills C. difficile spores using normal exposure times

53 Thoroughness of Environmental Cleaning Carling et al. ECCMID, Milan, Italy, May DAILY CLEANING TERMINAL CLEANING % Cleaned Mean = 32% >110,000 Objects HEHSG HOSP IOWA HOSP OTHER HOSP NICU OPERATING ROOMS ICU DAILY EMS VEHICLES AMB CHEMO MD CLINIC LONG TERM DIALYSIS

54 ENVIRONMENTAL CONTAMINATION LEADS TO HAIs Suboptimal Cleaning There is increasing evidence to support the contribution of the environment to disease transmission This supports comprehensive disinfecting regimens (goal is not sterilization) to reduce the risk of acquiring a pathogen from the healthcare environment

55 MONITORING THE EFFECTIVENESS OF CLEANING Cooper et al. AJIC 2007;35:338 Visual assessment-not a reliable indicator of surface cleanliness ATP bioluminescence-measures organic debris (each unit has own reading scale, < RLU) Microbiological methods-<2.5cfus/cm 2 -pass; can be costly and pathogen specific Fluorescent marker

56 TERMINAL ROOM CLEANING: DEMONSTRATION OF IMPROVED CLEANING Evaluated cleaning before and after an intervention to improve cleaning 36 US acute care hospitals Assessed cleaning using a fluorescent dye Interventions Increased education of environmental service workers Feedback to environmental service workers Regularly change dotted items to prevent targeting objects Carling PC, et al. ICHE 2008;29:

57 NEW NO TOUCH APPROACHES TO ROOM DECONTAMINATION Supplement Surface Disinfection Rutala, Weber. Infect Control Hosp Epidemiol. 2011;32:743

58 ROOM DECONTAMINATION UNITS Rutala, Weber. ICHE. 2011;32:743

59 ROOM DECONTAMINATION WITH UV, HP Issues-Room decontamination time; where the occupancy is high and fast patient turnaround time is critical Room decontamination with UV is minutes for vegetative bacteria and 50 minutes for C. difficile spores HP room decontamination takes approximately 2.5 hours

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61 Rapid Hospital Room Decontamination Using UV Light With a Nanostructured Reflective Coating Assessed the time required to kill HAI pathogens in a room with standard white paint (3-7% UV reflective) versus walls coated with an agent formulated to be reflective to UV-C wavelengths (65% UV reflective) Coating/painted uses nanoscale metal oxides whose crystal structures are reflective to UV-C Coating is white in appearance and can be applied with a brush or roller in the same way as any common interior latex paint Cost to coat walls used in this study was estimated to be <$300.

62 UV Reflective Coating Rutala, Gergen, Tande, Weber With the nanoscale reflective coating, cycle times were 5-10m (~80% reduction) which would substantially reduce the turnover time of the room Line-of-Sight MRSA w/coating MRSA no coating C. difficile w/coating C. difficile no coating Cycle Time 5m03s 25m13s 9m24s 43m42s Direct 4.70 (n=42) 4.72 (n=33) 3.28 (n=39) 3.42 (n=33) Indirect 4.45 (n=28) 4.30 (n=27) 2.42 (n=31) 2.01 (n=27) Total 4.60 (n=70) 4.53 (n=60) 2.91 (n=70) 2.78 (n=60)

63 SELF DISINFECTING SURFACES Surface impregnated with a heavy metal Silver Copper Surface impregnated with a germicide Triclosan Antimicrobial surfactant/quaternary ammonium salt? Organosilane products? Altered topography Sharklet pattern Light-activated antimicrobial coating Weber DJ, Rutala WA. ICHE 2012;33:10-13

64 SELF DISINFECTING SURFACES Copper coated overbed table Sharklet Pattern Antimicrobial effects of silver Triclosan pen

65 Enhancing Patient Safety Through Copper Surfaces M Schmidt et al. IFIC, October 2012 Three hospital (NY, SC) study to evaluate the potential value (reduced bacterial burden, HAIs) of antimicrobial copper applied to 6 touch surfaces in ICUs 83% reduction in bacterial burden Significant decrease in the incidence of HAI/colonization by MRSA and VRE Warrants further consideration when published to fully appreciate the potential benefit and optimization of the risk reduction

66 Environmental Strategies to Reduce Infections Environmental Infection Control Reprocessing reusable medical/surgical instruments Hospital surfaces Water Identify at least four ways infection prevention activities can reduce the contribution of the environment to HAIs

67 Water and Healthcare Multiple Uses CDC CDC

68 Water-Related Pathogens and Their Disease Transmission Pathways Exner et al. AJIC 33:S26-40; 2005

69 WATER RESERVOIRS Rutala, Weber. ICHE 1997;18:609

70 Water Wall Fountains and Electronic Faucets

71 Water Walls Linked to Legionnaires Palmore et al. ICHE 2009;30:764 2 immunocompromised patients exposed to decorative fountain in radiation oncology; isolates from patients and fountain identical; disinfection with ozone, filter and weekly cleaning Houpt et al. ICHE 2012;33:185 Lab-confirmed Legionnaires disease was dx in 8 patients; 6 had exposure to decorative fountain (near main entrance to hospital); high counts of Legionella pneumophila 1 despite disinfection and maintenance

72 Water Walls and Decorative Water Fountains Present unacceptable risk in hospitals serving immunocompromised patients (even with standard maintenance and sanitizing methods)

73 Electronic Faucets A Possible Source of Nosocomial Infection?

74 Conserve water Conserve energy Hygienic Hands free Barrier free Electronic Faucets

75 Electronic (E) vs Handle-Operated (HO) Faucets 100% E vs 30% HO Legionella (no cases). Halabi et al. JHI 2001:49:117 Significant difference HPC levels between brand A (32%) and B (8%) E compared to HO (11%). Hargreaves et al. 2001; 22:202 No difference in P. aeruginosa. Assadian et al. ICHE. 2002;23:44. 73% E samples did not meet German water standard vs 0% HO. Chaberny et al. ICHE 2004;25:997 39% of water samples from E and 1% from HO yielded P. aeruginosa. Merrer et al. Intensive Care Med 2005;31: % E grew Legionella compared to 45% HO (water-disruption events). Syndor et al. ICHE; 33:235

76 Issues Associated with Electronic Faucets A longer distance between the valve and the tap, resulting in a longer column of stagnant, warm water, which favors production of biofilms Reduced water flow; reduced flushing effect (growth favored) Valves and pipes made of plastic (enhances adhesion P. aeruginosa)

77 Prevention Measures Electronic faucets constructed so they do not promote the growth of microorganisms A potential source of nosocomial pathogens but more data are needed to establish role in HAI No guideline (but some have recommended) to remove electronic faucets from at-risk patient care areas (BMTU) Some have recommended periodic monitoring of water samples for growth of Legionella

78 Environmental Strategies to Reduce Infections Environmental Infection Control Reprocessing reusable medical/surgical instruments Hospital surfaces Water Identify at least four ways infection prevention activities can reduce the contribution of the environment to HAIs

79 Environmental Strategies to Reduce Infections Identify at least four ways infection prevention activities can reduce the contribution of the environment to HAIs Prohibit water walls/decorative fountains in hospitals serving immunocompromised patients Monitor effectiveness of cleaning Improve laryngoscope reprocessing Improve endoscope reprocessing Minimize surfaces as a reservoir for HA pathogens

80 CONCLUSIONS New sterilization, high-level disinfection and low-level disinfection technologies/practices/products are effective The contaminated surface environment in hospital rooms is important in the transmission of healthcare-associated pathogens (MRSA, VRE, C. difficile) Effective surface disinfection essential to eliminate the environment as a source for transmission of HA pathogens. New methods of reducing transmission of these pathogens may include: improved room cleaning/disinfection, no-touch methods (UV, HP), and self-disinfecting surfaces Water reservoirs of HA pathogens (e.g., water walls) may present unacceptable risk to high-risk patients

81 THANK YOU!

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